Evidence Based Screening, Brief Interventions and Treatment for Adolescent Substance Use - PowerPoint Presentation

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Evidence Based Screening, Brief Interventions and Treatment for Adolescent Substance Use Disorders

Leslie Hulvershorn, M.D. &

Zachary W. Adams, Ph.D., HSPP

Riley Adolescent Dual Diagnosis Program

Adolescent Behavioral Health Research Program

Department of Psychiatry

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Which drug of abuse is most commonly used by Indiana’s 12th graders?

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Adolescent Substance use in IN

https://

inys.indiana.edu

/survey-results

Alcohol

: 32.2%

Cannabis

: 18.4%Cigarettes: 12.8%E-Cigarettes: 19.7%Rx Drugs: 3.7%Heroin: 0.2%

Past-month, 12

th

grade

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Adolescent SU/SUDs are a Top Predictor of Opioid Misuse and OUDs

Opioid Misuse

Opioid A/D

Alcohol A/D

Alcohol A/D

Age (yrs)

No

Yes

No

Yes

12-17

2.5%

32.2%

0.3%

9.3%

18-25

5.7%

21.8%

0.9%

4.6%

Marijuana A/D

Marijuana A/D

Age (

yrs

)

No

Yes

No

Yes

12-17

2.5%

29.5%

0.3%

8.7%

18-25

6.1%

28.3%

1.0%

5.9%

NOTE

.

Data from 2017

NSDUH, retrieved from

pdas.samhsa.gov

.

All variables based on past-year. A/D=Abuse or dependence per DSM-IV.

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Evidence Based Screeners

BSTAD

2BI

CAGE

Promising: CAT

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ASSESSMENTS

“Biopsychosocial” +:

KSADS

DUSI

Center for Substance Abuse Treatment. Screening and Assessing Adolescents for Substance Use Disorders. Treatment Improvement Protocol (TIP) Series, No. 31. HHS Publication No. (SMA) 12-4079. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1998.

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*The conditions/environment at the time of assessment

*The severity of the substance involvement

*Youth’s conceptualization of reasons for substance use *Factors that contribute or relate to the substance involvement

*Diagnosis as defined by the DSM-5

*History of treatment services, including drug treatment and mental health treatment

*Treatment recommendations

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How to treat adolescent SUDs?

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NIDA Adolescent SUD Treatment Principles

Adolescent substance use needs to be identified and addressed as soon as possible.

Adolescents can benefit from a drug intervention even if they are not addicted to a drug.

Routine annual medical visits are an opportunity to ask adolescents about drug use.

Legal interventions and sanctions or family pressure may play an important role in getting adolescents to enter, stay in, and complete treatment.

Substance use disorder treatment should be tailored to the unique needs of the adolescent.

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NIDA Adolescent SUD Treatment Principles

Treatment should address the needs of the whole person, rather than just focusing on his or her drug use.

Behavioral therapies are effective in addressing adolescent drug use.

Families and the community are important aspects of treatment.

Effectively treating SUDs in adolescents requires also identifying and treating any other mental health conditions they may have.

Sensitive issues such as violence and child abuse or risk of suicide should be identified and addressed.

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NIDA Adolescent SUD Treatment Principles

It is important to monitor drug use during treatment.

Staying in treatment for an adequate period of time and continuity of care afterward are important.

Testing adolescents for sexually transmitted diseases like HIV, as well as hepatitis B and C, is an important part of drug treatment.

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What are some evidence based treatment modalities that can help adolescents with substance use disorders?

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Components of Well Established, Effective Treatments

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Common Goals

Reduce

substance use (behavior)

Enhance motivation and efficacy in reducing use

Identify and target drivers of substance use problems

External, Environmental

Internal

Bolster protective factors against substance abuseReplace needs met by substance use with more adaptive strategiesActivating the reward system in other ways!Encourage and link to prosocial activitiesMonitor use with random screening (ideally by caregiver)

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Evidence-Based Psychotherapy Models(Outpatient)

Level of Support

Treatments

1: Works well, Well-established

Cognitive Behavioral Therapy

(CBT; individual,

group)

Family-based treatment (ecological; MDFT, FFT, EBFT)Combined MET/CBTCombined MET/CBT/Family-based treatment (behavioral)2: Works, Probably efficaciousFamily-based treatment (behavioral)Motivational interviewing/Motivational enhancement therapy (MI/MET)Combined family-based treatment (ecological)/Contingency Management (CM)Combined MET/CBT/Family-based treatment (behavioral)/CM3: Might work, Possibly efficaciousDrug counseling/12-stepHogue, Henderson, Ozechowski, & Robbins, 2014, JCCAP

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ENCOMPASS (

MET+CBT+CM+Family+Medication

)

Diagnostic evaluation and baseline measures

Weekly, individual CBT + MI + 3 family sessions

Week 1:

Personal rulers (ready/willing/able), Supportive People, Functional Analysis of Pro-Social ActivitiesWeek 2: Personal Feedback (develop discrepancy), Goal Setting, Happiness Scale, Summarize change talkWeek 3: Functional Analysis of Drug Use Behavior, Patterns of Use Expectation of Effects, Consequences of Use13 Skills Training Modules:Coping with cravingsCommunication Managing angerNegative moodsProblem solvingRealistic refusal skillsSupport systemsSchool & employmentCORERiggs et alCoping with a slipSeemingly irrelevant

decisions

HIV prevention

Saying goodbye

Bringing in the family

(3 sessions)

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Sequence and Selection of Modules

Core Modules (1,2,3) done at the beginning

Skills modules can be done in any order

Functional analysis should guide selection of modules/individually-tailored treatment

Use CBT supervision for guidance on when to introduce sessions (and/or repeat)

You can repeat or expand the # sessions devoted to specific modules

Better to cover more in detail than to rush through material

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True or False?: Adolescents need to be ready to change for treatment to work.

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Assume AmbivalenceExpected, natural part of changeBe on the lookout for

CHANGE TALK

Desire, Ability, Reason, Need

Can also evoke and respond to change talk in strategic ways

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MI/MET

“Motivational Interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.”

Miller &

Rollnick

, 2013

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What happens when we tell people WHY and HOW they should change?

COMMON

REACTIONS TO

RIGHTING REFLEX

Angry

Afraid

Agitated

HelplessOverwhelmedOppositionalAshamedTrappedDefensiveDisengagedJustifyingUncomfortableIgnoredNot understoodDiscounting of ideasUnlikely to come back

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When we use MI…

COMMON

REACTIONS TO

FEELING HEARD

Understood

Engaged

Want to talk more

Able to changeLike the counselorSafeOpenEmpoweredAcceptedHopefulRespectedComfortableInterestedCooperativeConfidentLikely to return

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What are some strategies that a person can use to evoke “change talk” in another person?

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Evoking Change Talk: OARSOpen ended questions

Affirmations

Reflections*

Summaries

GOAL

: ELICIT and REINFORCE CHANGE TALK

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Module 1: Motivation & Engagement

Convey sprit of MI

Partnering, joining

Emphasize personal choice, support self-efficacy

Avoid “problem” language

Develop discrepancy between values and behavior

Sidestep or roll with resistance

– respond with accurate empathy, understandingWill explore feelings and thoughts to understand behaviorWill discover and experiment to find what works to change

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Module 1: MI Ice Breakers

Prior therapy experience

What have your therapy experiences been like?

What did you like? What didn’t you like?

What was helpful? What wasn’t helpful?

What do you hope to get out of this therapy?

People often come here because others want them to. I’m interested in what you think about the situation.

Tell me why you decided to participate in this treatmentWhat are some concerns you have in your life right now?Follow with OARS!

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Module 1: Ruler Questions

Importance

(reasons to make change)

Confidence

(self-efficacy)

Readiness (timing, conditions)Follow-up Questions (goal: elicit change talk!)Why are you a <rating> and not a <lower number>?What would it take to get you from a <rating> to a <higher score>?

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Module 2: Personal Feedback and Goal Setting

Why is Goal Setting Important?

Foster sense of direction

Help patients feel more hopeful

Prevent therapist drift

Reinforce collaboration

Evaluate therapeutic progress and outcome

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Module 3: Functional Analysis & Exploring High Risk Situations

Better understand the

function

and

triggers

for substance use (behavior) before developing treatment plan to individualize intervention

Encourage an interactive and collaborative process which will be continued in the next phase of treatment (skill acquisition).

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Module # 3: Functional Analysis

Explore links between thoughts, feelings, & behavior

Identify triggers for cravings and substance use

Compare the “pros” (positive consequences) and “cons” (negative consequences) of substance use using a decisional balance

Teach patients to become

“

experts

” about their own habits (self-efficacy)Motivate and enhance readiness for change, action, and commitment

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Functional analysis tipsStart with behaviorUse MI throughout

Complete FA for each substance

Be thorough

–

avoid premature focus

Use as a roadmap throughout treatment

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Contingency Management

Strong data to support decrease in drug use in adults and adolescents

“

Prize draws

”

for positive target behaviors:

Session attendance

Negative urine drug screen (UDS) – immediate feedbackPro-social activitiesBonus prizes for sustained or early abstinenceBuilds motivation for engagement and treatment progress

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Family InvolvementParental monitoring/effective limit settingHome based contingency management (positive reinforcement)

Communication strategies

Referrals for parental treatment

Can be structural or strategic work

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Comorbidities (80-90%)Externalizing Disorders

ADHD, ODD, CD

Internalizing Disorders

Depressive Disorders

Anxiety Disorders

Psychotic Disorders (less common)

PTSD

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Medication Management of Psychiatric Comorbidities

PARTICULARY BENEFICIAL WITH MEASUREMENT BASED CARE

-Depression: antidepressants

-Psychosis: antipsychotics

-OCD: antidepressants

-Anxiety: antidepressants (not benzos!)

-ADHD: atomoxetine/alpha agonists, stimulants*

-

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Which medications can be helpful in reducing drug/alcohol use in adolescents?

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Medications Improve Outcomes in adolescents with the following use disorders

-Opioids

-Nicotine

-Alcohol

-Cannabis

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Opioids

All forms of timely MAT improve retention in care (

Hadland

2018)

Naltrexone: Safe in youth, not much data, still likely a good choice

Agonists (Buprenorphine, Methadone, LAAM): Only 2 trials

One study, with 35 participants, compared methadone with

levo-alpha-acetylmethadol (LAAM) for maintenance treatment lasting 16 weeks, after which patients were detoxified. No difference. The other study, with 154 participants, compared maintenance treatment with buprenorphine-naloxone and detoxification with buprenorphine. Maintenance is helpfulNo placebo controlled RTCs: Risks are too great(Carney 2018: MAT for Adolescent OUD in Primary Care, Pediatrics Reviews)

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Nicotine

NRT: Patch is the better tolerated. Works as well as gum. Negative pilot with nasal spray (Rubenstein 2009)

Bupropion: 4 RCTs

Varenicline (Chantix): Promising, concerns about mental health related

side effects

(Bailey 2012)

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Alcohol

Benzos for severe withdrawal (rare)

Naltrexone (50 mg PO daily): Reduced likelihood of drinking and heavy drinking, blunted cravings, altered response to consumption in 22 15-19 year

olds

(Miranda 2014)

Consider IM Naltrexone (Vivitrol) as well

Acamprosate: 2012 Paper retracted

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Cannabis

N-acetyl Cysteine (NAC): Doubled odds for negative UDS in RCT with 15-21 year

olds

. (Gray et al 2012) (600-1200 mg BID)

“NAC was more effective at promoting abstinence among adolescents with heightened baseline depressive symptoms” (Tomko et al 2018)

Also reduced alcohol consumption (

Squeglia

et al 2018)Topiramate has been found to be a helpful adjunct, but not well tolerated due to memory difficulties (Gray 2018)NOT helpful in adults

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Evidence-Based Treatments

NIDA Principles of Adolescent Substance Use Disorder Treatment:

A Research-Based Guide

www.drugabuse.gov

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Riley Adolescent Dual Diagnosis Program

317-948-3481

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Project ECHO

Free

continuing education and consultation

oudecho.iu.edu

oudecho@iu.edu

Adolescent SUD TrackEvery other Weds 12-1:30p

Child/Adolescent Mental HealthComing soon!